A case of severe vasculopathy of the carotid arteries of the neck in a patient with HIV

A 72-year-old male patient with newly diagnosed carcinoma of the head of the pancreas and HIV performed a Colour Doppler ultrasound of the vessels of the neck, which is routinely performed in our institution in patients with a new diagnosis of HIV. He had a history of weight loss, which started 4 months before, and epigastric pain. Previous clinical history was unremarkable. Based on the findings emerged, computed tomography angiography (CTA) was done.

On CTA, there was a saccular aneurysm of the right common carotid artery (Figure 1) and complete occlusion of the ipsilateral internal carotid artery due to a voluminous soft atheromatic plaque (Figure 2). Furthermore, the left common carotid artery was dissected with an intimal flap (Figure 3). There was also subocclusion of the ipsilateral internal carotid artery due to soft atheromatic plaque (Figure 4).

Human immunodeficiency virus (HIV) is a common infection affecting almost 75 million people worldwide, which is caused by a lentivirus that invades lymphoid tissue [1]. It can be caused by HIV-1 virus (which is found worldwide) and HIV-2 (most frequent in West Africa). The infection manifests firstly with a fever lasting some weeks, followed by a long asymptomatic phase where the immune system is progressively destroyed by the virus. After this phase, an acquired immunodeficiency syndrome (AIDS) occurs, which manifests with opportunistic infections. Antiretroviral therapy is effective, especially during the quiescent phase.

In HIV, vasculopathy may occur in advanced disease, and it is thought to be related to inflammation of the vasa vasora, with transmural necrosis of the vessels’ wall [2]. It is still debated if vasculitis in HIV is directly caused by the virus or if it is related to the immuno-complex mechanism. On the other hand, opportunistic infection does not seem to play a role.

Vasculopathy manifests with multiple aneurysms and diffuse occlusive disease mainly due to non-calcified atheromatous plaques [3]. Aneurysms tend to be multiple and located in the carotid arteries. Clinically, they are asymptomatic for a long time, until rupture or complete occlusion. Therefore, in these patients, imaging plays a crucial role, and thus, it should be performed in asymptomatic patients too. Advanced cases may require vascular surgery.